Tag Archives: covid19

Return to Non-Emergent Care: Common Reopening Challenges Facing Your Practice

As practices begin to reopen to serve the needs of patients and begin delivering non-emergent care, many physicians may be wondering what the appropriate protocols in the pandemic environment are and how best to support their patients at this time. In addition, the new clinical setting presents its own set of challenges that require a strategic and unified approach. Physicians must now balance the need for in-person visits – which are crucial for critical medical care and revenue generation – with the risk of COVID-19 spread. Telemedicine has proven an adequate solution to patient management, however, it may not be a sufficient method of delivering care for all patients and some demand in-office appointments despite the ongoing virus spread.

Dr. Sachin Dave, an internist of the Indiana Internal Medicine Consultants stresses the importance of educating patients and communicating the risks to them. “My older patients actually insist on coming to see me in person,” he told Medscape in an interview, “I have to tell them it’s not safe.” Minimizing risk is paramount in the process of reopening medical practices across the United States and the globe; physicians must weigh the risks of increasing patient volume with patient and staff safety.

To assist healthcare practitioners in safely transitioning back to in-person care, Medscape has outlined some common challenges they may face in the reopening process, and how best to mitigate them.

1.     Unclear or Nonexistent Policies and Protocols

While physicians and other staff members may be aware of the COVID-19 prevention rules implemented to help mitigate virus transmission, patients need to be made aware of them preferably in a readily available document; it is important to develop formal protocols for all to follow to minimize confusion and ensure safety.

This includes enforcing mandatory mask wear for both staff and patients, setting up facilities in accordance with social distancing guidelines, having alternate waiting areas or asking patients to wait in their cars if the space gets too crowded, and other protective strategies.

Ensure all patients understand and agree to adhere to your new policies before they come in; in addition, they should be triaged over the phone per CDC guidelines before attending an in-office visit. Without a formal framework, refusing care or assessment of patients who do not comply with guidelines may lead to patient abandonment claims, making clear policies paramount at this time.

2. Too Many Patients, Too Soon

According to data from the Medical Group Management Association (MGMA), practices report an average 55% decrease in revenue and 60% decrease in patient volume since the COVID-19 crisis began. As a result, experts believe practices may be tempted to ramp up capacity immediately to restore prior patient volume. However, this period requires slow and carefully implemented safety protocols.

Physicians and their patients are encouraged to take advantage of telehealth services while they remain reimbursable at parity. The elevated demand for online care is forecasted to continue growing as more patients become comfortable with the technology and services become more advanced. While some doctors want to see an overload of patients immediately upon reopening, there has to be a limit on the number of patients coming into an office as welcoming too many patients too fast can have dire consequences.

3. Lack of Communication

Another potential pitfall is under-communication; patients may not be aware that your practice has reopened or plans to do so. It is important to consistently update your practice’s website, send out letters or newsletters to patients, maintain phone and email contact, post signs explaining reopening protocols, and keep everyone in the loop. The CDC has provided phone advice line tools that practices can adapt to their needs to keep patients informed.

Instead of under-communicating, physicians are encouraged to over-communicate to their patients as well as their staff, making sure they are made aware of the extra precautions being taken to prioritize their health and safety. Practice staff should also be aware of policy changes to minimize confusion.

Experts believe that practices can emerge stronger from the pandemic if they promote strong patient education and build up goodwill at this time. Leverage the patient portal, using it as a trusted resource to inform patients about COVID-19 and preventative measures being taken at your practice.

4. Inadequate Staff Training

Some staff members may be apprehensive about returning to work as a result of virus-related fears. Clear guidance is needed to ensure safety, manage expectations, and offer flexibility with scheduling to address potential challenges before they occur.

Properly training staff members is essential to their safety and that of your patients; specific guidelines for staff – such as designating eating areas, staggering appointments – should be clearly articulated and readily available. Many staff members may not be used to donning and removing personal protective equipment or wearing masks when working with patients. Training staff members will help reassure patients that safety protocols are being adhered to.

5. Neglecting Documentation

With the changing standard of care, a consistent workflow is paramount. This includes proper documentation, communication with staff and patients, and the use of established systems aimed at mitigating COVID-19 risk. Experts recommend keeping an administrative file used to track new protocols, policies, and any incidents or breaches for future use.

6. Forgetting About Personal Mental and Physical Health

Physicians should be cognizant of the high potential of burnout and mental health state  of their staff, their colleagues, and themselves. Mental exhaustion as a result of the persisting COVID-19 crisis and ongoing societal tensions is affecting all members of the population and has the potential to carry over to medical practices. To protect their mental and physical health as well as that of their staff members, physicians are encouraged to prioritize maintaining a positive culture at their practice – one in which everyone feels safe, taken care of and helps each other.

Practices and healthcare professionals located in areas which have deemed non-emergent care facilities eligible to reopen safely should take into consideration the aforementioned challenges and common pitfalls that may impede a smooth return to routine care. For those in search of comprehensive reopening recommendations and guidelines, The Doctors Company has developed an extensive checklist outlining the necessary steps for transitioning to in-person care – accessible here.

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Addressing a Dysfunctional Healthcare System During a Pandemic

In the battle against the novel coronavirus (COVID-19) outbreak sweeping across the globe, healthcare workers are the frontline fighters saving countless lives with their tireless efforts. Grueling hours, equipment shortages, increasing patient needs, and dangerous working conditions on top of already demanding job requirements are contributing to unprecedented levels of physician burnout at this time.

Not only are healthcare workers facing the global pandemic head on, they are doing so without the necessary safety precautions, as part of a healthcare system that is proving more dysfunctional and ill-equipped to handle a public health emergency than would have been assumed. The precarious situation is made worse by mounting evidence of the censorship and exploitation of medical professionals, who are in some circumstances being forced to choose between their jobs and sharing accounts of what the battle within hospitals really looks like. The issues coming up as a result of the pandemic devastating healthcare systems across the globe is an extension of a greater, long-term problem within the healthcare system that must be addressed.

Growing Censorship

It has become commonplace for hospital and healthcare organization leadership to take on press and media responsibilities, while the voices of physicians tend to be largely omitted in the news landscape.

Now due to the COVID-19 pandemic, news channels and other media are actively seeking input from physicians fighting the global health crisis, giving them an unprecedented opportunity to air their concerns about the state of the healthcare system on a public platform. Unfortunately, their employers and hospital leadership are actively working to suppress their ability to speak out and provide honest depictions of working conditions.

More frequently, stories are emerging of physicians who have lost their jobs for speaking out against hospital protocols, posting their stories on social media, or releasing information to the media. Dr. Esther Choo, emergency physician at Oregon Health & Science University, revealed she has been told by many fellow healthcare providers about their fears of speaking up about the challenges they are facing due to the risks involved.

Some physicians have been taking their concerns to social media, posting about dangerous shortages of personal protective equipment, unsafe hospital protocols, a lack of communication from leadership, as well as growing censorship and restrictions on their freedoms. According to reports, hospitals across the nation have been warning, disciplining, and even terminating employees who publicize their workplace concerns about coronavirus-related challenges.

Accounts reported in The Washington Post and The New York Times, describe several instances of physicians being threatened with disciplinary action, restricted from appearing on television, reprimanded for their behaviors, and even terminated for sharing glimpses into their hospital’s conditions. While other institutions such as NYU Langone Medical Center in New York have gone so far as to forbid staff members from “contacting the media without permission under threat of termination” according to an article published in The Washington Post.

During a worldwide pandemic, the worst thing that can be done is to render clinicians inconsequential and sequester them from the rest of the world when knowledge of the realities is critical to improving population health outcomes worldwide. Their first-hand perspective from the frontline is necessary both in terms of guaranteeing freedom of speech as well as providing an accurate depiction of the handling of COVID-19 within the healthcare system.

Increased Press Access

Hospitals, while not in the business of sharing information about their patients, currently face growing pressure to provide insight into the situation at hand. Protecting the privacy and dignity of patients is paramount, however, Dr. Esther Choo told CNN she believes this unprecedented situation warrants an alternative approach to sharing healthcare information.

“In this crisis, I think it creates a barrier between what is happening inside, what our healthcare workers are seeing, and what the public needs to know in terms of how bad this disease is,” Dr. Choo commented on the lack of insight provided from within the healthcare system,  “I think without seeing it, it’s hard for people to understand what we’re trying to avoid with measures like stay-at-home.”

While for both safety and privacy reasons journalists are unable to report from emergency departments or within hospitals, media professionals are calling for more access and exposure to vital information. This makes the first-hand, honest reports from physicians and nurses essential at this time – they have the power to inspire widespread reform, motivate support and donations, and underscore the importance of staying home.

Relaxing HIPAA regulations and revisiting press restrictions at hospitals may be necessary at this time to provide the public with an honest view inside emergency rooms. “I think we need to make a decision as hospitals, as healthcare systems, we are going to be a little bit more open about the challenges we’re facing,” Dr. Esther Choo told CNN, highlighting the systemic effort needed to change the status quo.

Access to information is not only vital for preserving democracy within the nation, but it is critical for public health, keeping the population informed and aware of the devastating failures of hospital protocols as evidenced by the COVID-19 response. This can be achieved while still protecting patient privacy and anonymity, if healthcare professionals are allowed to speak out. As reporter Chandra Bozelko argues in a recent Washington Post article, “Patient care includes public advocacy, minus the personal details.”

Emotional Exploitation

Alongside the censorship of medical professionals, the exploitation of physicians is another problem emerging as a result of the dysfunctional system. Viewed as a perpetual resource, healthcare staff members, their innate professionalism, and their work ethic are what keeps the healthcare industry in operation. The system itself runs on the altruism of its practitioners; if medical professionals worked their number of allotted hours and went home at the end of their shift – instead of working endless hours overtime to preserve patient health – the healthcare system and its patients would suffer greatly.

The COVID-19 pandemic has revealed how medical staff members are treated as an endless resource, used to maximize efficiency of the system, constantly being faced with added responsibilities and a growing workload – additional patients, paperwork, and procedures. For the majority of healthcare workers, walking away without completing their job and thus, endangering patients is unthinkable. Meanwhile leadership continuously exploits this ethic.

Over the past few years, demands have escalated without an equivalent rise in time or resources. At the same time, the medical complexity of patients has increased with the number and severity of chronic conditions steadily rising in prevalence. Medical encounters are more involved than ever before with more illnesses, medications, and complications, while the duration of office or hospital visits remains the same.

In times of the COVID-19 pandemic, the demands on healthcare workers have only increased, while resources continue to decrease at alarming rates and exploitation of the workforce continues. According to data from The New York Times, physician burnout levels are at an all-time high caused in part by chronic workplace stress, as are burnout rates among nurses. Physicians and nurses on the frontline of patient care experience the highest levels of burnout, which are associated with increased medical errors and thus, present threats to patient health and safety. Data suggest that doctors and nurses commit suicide at higher rates than in almost any other profession and recent examples of medical workers taking their own lives as a result of working conditions signal an urgent need for change.

Based on an unrelenting belief in the unwavering professionalism of its workers, the current healthcare model is proving unsustainable for both providers and their patients. As such, the system must be restructured to reflect the current realities of patient care. The healthcare model is  imperfect and is only able to function due to the valiant efforts of its workers who prize patient caregiving above all else. Exploiting the altruistic ethic of healthcare professionals to keep a broken system from collapsing in on itself is not just unsustainable, it goes against its very mission.

Though limited due to censorship restrictions, reports emerging from the frontline indicate a persisting problem. The COVID-19 pandemic has revealed the unpreparedness of many healthcare systems across the world to handle unprecedented spikes in demand. However, in the United States it has also presented an ominous example of dysfunction and an extension of a greater, long-term problem within the system that must be addressed. The number of challenges facing healthcare workers will continue to grow as long as the enterprise can exploit its labor force unpenalized and the repercussions of this model will continue to emerge. Silencing staff members will only further the problem while promoting an unrealistic image of the state of healthcare thereby hindering potential efforts to help those in need – which right now are not just the patients fighting for their lives against COVID-19, they are also the physicians risking their lives to protect them.

 

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Medicare COVID-19 Telemedicine Factsheet

The COVID-19 outbreak has not only disrupted daily life across the globe, but the contemporary healthcare model as well, with an urgently needed shift to digital medical solutions. Federal regulations are changing continuously, insurance coverage has greatly expanded, and the use of telemedicine is growing at a tremendous rate assisted by new policies and a widespread loosening of restrictions previously impeding access to care.

As part of the battle against the novel coronavirus pandemic, the Centers for Medicare & Medicaid Services (CMS) have expanded access to Medicare telehealth services on a temporary and emergency basis and lessened HIPAA enforcement effective as of March 6, 2020. These updates offer Medicare beneficiaries – many of whom are at an increased risk for serious COVID-19 illness – a safe, alternative model of care in the form of a wider range of remote services. During the COVID-19 crisis, innovative uses of telemedicine technology are driving routine care, keeping vulnerable demographics safe, and expanding access to health care. 

“The benefits are part of the broader effort by CMS and the White House Task Force to ensure that all Americans – particularly those at high-risk of complications from the virus that causes the disease COVID-19  – are aware of easy-to-use, accessible benefits that can help keep them healthy while helping to contain the community spread of this virus,” a statement from the CMS on the promotion of telemedicine reads. Further information about the newly implemented guidelines for patient care and their implications on telehealth services during the COVID-19 outbreak are outlined below.

Expansion of Telehealth Services

1135 Waiver

As part of the program, the 1135 waiver was introduced to lessen prior restrictions and promote wider access to remote care. Prior to the waiver, Medicare was only able to pay for telehealth on a limited basis, for example, when a patient was receiving care in a designated rural area or when received the service in a healthcare facility. Under this waiver, the following changes have taken effect:

•   Office, hospital, and other telehealth visits will now be covered and reimbursed for the same amount as an in-person visit.
•   A wide range of providers can offer telehealth services across the nation, including nurse practitioners, psychologists, and licensed social workers.
•   Medicare beneficiaries are now be able to receive a wider variety of services through telemedicine – such as evaluation and management visits, mental health counseling, and preventative health screenings.
•   The HHS Office of Inspector General is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs during this time.

Virtual Services 

Medical professionals can provide their Medicare patients with a range of virtual services as part of the telehealth program, including Medicare telehealth visits, virtual check-ins, and e-visits. Specific requirements for each service are outlined below.

Medicare Telehealth Visits

Throughout the course of the COVID-19 outbreak, Medicare patients may use digital technology for office, hospital visits, and other services previously rendered in-person. The recent changes include:

•   A wider range of practitioners is now able to get payment covered for telemedicine services – including physicians, nurse practitioners, physician assistants, midwives, anesthetists, psychologists, clinical social workers, registered dietitians, as well as nutritional professionals.
•   Virtual visits will now be paid at the same rate as regular, in-person visits.
•   Providers must use an interactive audio and video system permitting real-time communication during Medicare telehealth visits in order to be reimbursed appropriately.
•   New CMS guidelines remove the requirement of an established patient-provider relationship for the duration of the public health emergency, further details below.

“The Department of Health and Human Services (HHS) is announcing a policy of enforcement discretion for Medicare telehealth services furnished pursuant to the waiver under section 1135(b)(8) of the Act.  To the extent the waiver (section 1135(g)(3)) requires that the patient have a prior established relationship with a particular practitioner, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency,” the CMS statement reads.

Virtual Check-ins

In all areas of the country, Medicare beneficiaries will be able to have brief online check-ins with practitioners – or brief communication technology-based services. Policy changes related to this include:

•   Medicare will now pay for virtual check-ins for patients with established relationships with their physicians to prevent unnecessary travel and office visits.
•   Brief virtual check-ins can be conducted using a broader range of communication methods than Medicare telehealth visits; medical practitioners may bill for virtual check-in services provided via several telecommunication technologies – including telephone, audio/video, secure text messaging, email, and patient portals.
•   Services cannot be related to a medical visit within the previous 7 days or lead to a medical visit within the following 24 hours, or the soonest available appointment.
•   Patients must verbally consent to receive virtual check-in services.
•   Patients can submit video/images using store and forward methods to be interpreted by physicians within 24 business hours.
 

E-Visits

As part of the updated guidelines, established Medicare patients in all types of locations can have non-face-to-face patient-initiated communications with their providers using online patient portals. These services can only be rendered in accordance with the following guidelines:

•   E-visit services can only be reported to Medicare if the billing practice has an established relationship with the patient.
•   E-visits must be initiated by the patient although, practices may educate patients on the availability of these services prior to their initiation.
•   Communications can occur over a 7-day period and only after the patient provides verbal consent to receive telehealth services.
•   These services may be billed using CPT codes 99421-99423 and HCPCS codes G2061.
More information on relevant billing codes for e-visits and other virtual care services can be found on the CMS’ website.

Health Insurance Portability and Accountability Act (HIPAA) Updates 

In addition to the amendments above, the HHS Office for Civil Rights will lessen restrictions and waive penalties in association with HIPAA compliance for health care providers that serve patients in good faith through virtual communication technologies during the COVID-19 outbreak. More information on the latest HIPAA updates can be accessed here.

Although Medicare already offers flexibility to states that wish to implement telehealth services, the most recent developments signal a major step forward in the direction of telemedicine, despite the temporary nature of federal guidelines. With the help of changes in regulations and the strategic expansion of telehealth, patients can now reach providers easily via a range of tele communication options from the comfort and safety of their homes, while medical professionals can readily provide care without reimbursement concerns. As the COVID-19 public health emergency continues to evolve rapidly, regulations and guidelines may change; clinicians are encouraged to stay up-to-date on the latest medical guidance.

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